Provider First Line Business Practice Location Address:
207 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 2-J
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-5747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-631-0075
Provider Business Practice Location Address Fax Number:
423-631-0079
Provider Enumeration Date:
09/22/2010